What are Children’s Elbow Injuries?
The bones of the elbow joint consist of the humerus of the upper arm and the radius and ulna of the forearm, whose bony articulations fit together like pieces of a puzzle, allowing hinge-like motion in the joint. The medial and lateral ligaments of the elbow lend support to the joint, along with the muscles and the tendons of the arm. Children’s Elbow injuries occur when any of these structures are damaged in a child or adolescent, and include Nursemaid’s Elbow, Little League Elbow, Tennis Elbow, Panner’s Disease, and Osteochondritis Dessicans. Elbow Fractures are also common in children. Children are especially prone to injuries of the elbow because of their high level of activity, and their growing, immature bones and ligaments.
Also known as subluxation of the radial head or “pulled elbow”, Nursemaid’s elbow occurs when the annular ligament, which wraps around the radius bone at the elbow, gets displaced and becomes trapped in the joint space between the radius and the humerus. It occurs exclusively in children under age five because the annular ligament reaches maturity at that age, becoming stronger and thicker, resisting displacement.
Little League Elbow
Also known as medial epicondylar apophysis, Little League Elbow is an injury of the growth plate on the medial epicondyle of the humerus. The medial epicondyle, palpable as the bony bump on the inside of the elbow joint, is where muscles responsible for rotating the forearm to a palms down position attach. The medial epicondyle’s growth plate is weaker than the permanent bone that will later replace it. Repeated stress on the muscles and tendons that attached here can cause the growth plate to crack, tear, or even break away from the humerus bone. This can adversely affect bone growth or cause deformity of the elbow.
Tennis Elbow is an injury which may occur in children who play racquet sports.
Panner’s Disease, found in children ages 5-12, is caused by a yet unknown factor interfering with the blood supply to a portion of the growth plate on the humerus called the capitellum. The capitellum articulates with the radius at the elbow joint. The lack of blood supply results in the death of the cells of the growth plate causing collapse of the bone in this area. Fortunately, bone tissue is constantly remodeling, and the body is able to eventually repair the bone. Thus, this condition is usually self-limiting.
Osteochondritis Dessicans (OCD) involves the capitellum of the humerus, just like in Panner’s disease. In OCD, however, the child is of adolescent age and the growth plate of the capitellum has closed and has been replaced by mature bone. Lack of blood supply in this case results in damage to the articular cartilage of the capitellum and the bone beneath it. In severe cases, the tip of the radius bone can also become damaged.
What are the causes of Children’s Elbow Injuries?
Nursemaid’s elbow is caused by pulling on the arm when the arm is outstretched with the palm facing down. This occurs when a child is pulled by the arm or the arm is yanked. It can also occur when a child falls onto his outstretched arm with the elbow hyperextended.
Little League Elbow is caused by throwing a ball repetitively and excessively, as occurs in baseball or softball pitchers.
Tennis Elbow is caused by repetitive use of the muscles of the forearm coupled with extension of the wrist, as occurs frequently in those who play racquet sports.
The true cause of Panner’s Disease is unknown. It is believed to be a combination of genetic predisposition and overactivity. It occurs in children who stress the elbow joint through weight bearing exercises like gymnastics or overuse the elbow in throwing sports.
Osteochondritis Dessicans similarly has the same causes as Panner’s Disease, but occurs in older children and adolescents.
How are Children’s Elbow Injuries Diagnosed?
Most elbow injuries in children are based on the history and physical. X rays may be utilized if a fracture is suspected. When obtaining X rays of the elbow in children, it is important to get an X ray of the unaffected elbow for comparison as bone development can vary widely among children.
In Nursemaid’s Elbow the history will reveal a sudden onset of pain with a pull on the arm or a fall. There will be no swelling or deformity noted, and the child will hold the arm protectively at his side either straight down or with a slight bend to prevent the pain with movement.
In Little League elbow, there will be a history of pain located at the bony bump on the inside of the elbow joint. It may have a gradual onset or may have occurred after a particular throw. Redness, swelling and warmth may be present.
In Tennis elbow, tenderness, pain, and/or swelling at the lateral epicondyle is the classic presentation. Pain can also be elicited by extending the wrist against resistance when the elbow is held straight.
In Panner’s disease, there is a complaint of a dull ache in the lateral elbow not associated with any particular event. Physical exam reveals tenderness and swelling with some being unable to fully extend the elbow. Xrays are diagnostic in this condition and will show flattening of the capitellum.
In Osteochondrititis Dessicans elbow pain will gradually worsen over time. The elbow may feel stiff and may be unable to extend completely. In severe cases a grinding sensation of the joint may occur, and the elbow may lock up. Xrays, MRI, or CT may be used to confirm the diagnosis and stage the severity of the condition.
How are Children’s Elbow Injuries Treated?
Nursemaid’s elbow can be treated non surgically in the office or emergency department by closed reduction.
If Little League Elbow is caught early, it can be treated non-surgically. The child is required to rest and not participate in sports for a period of 4-6 weeks. If the injury to the growth plate is more severe, a cast may be placed for this time period to insure immobilization and healing. Physical Therapy is recommended to help the child return to sports by gradually increasing the amount of throwing allowed.
Tennis elbow in children is almost exclusively treated non-surgically in children. Rest, use of a counterforce brace, NSAIDS, and stretching and strengthening exercises, and ensuring proper fit of equipment and correction of technique result in great outcomes in the pediatric population.
Because Panner’s Disease is self-limiting, rest is all that is usually needed to treat the condition. Ice, splinting and NSAIDs may be used to alleviate symptoms. Usually within 1-2 years the growth plate of the capitellum has matured and the new bone returns the capitellum to its original contour and its increased strength can withstand the forces that previously crippled it.
Osteochondritis Dessicans does not always share the same rosy outcome as Panner’s Disease. If not caught early and treated aggresively, the elbow may develop permanent sequelae such as arthritis or inability to return to full range of motion. Rest, possibly with immobilization of the elbow in a splint, is prescribed early on. Physical Therapy is involved to help rehabilitate the elbow and teach proper technique when using the elbow. Surgery is needed in severe cases.
In severe cases of Little League elbow, open reduction and internal fixation with pins or screws may be needed to reattach the growth plate to the bone.
Severe cases of Osteochondritis Dessicans may require surgery, and can be done arthroscopically.
Why See Dr. Knight for children’s elbow injuries?
Dr. Knight has extensive experience with elbow injuries and specializes in the care of the hand and arm. He is board-certified in orthopedics and uses minimally invasive, state-of-the-art technology to promote faster healing and less pain.
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